When women in Portsmouth were reluctant to make a considered choice about where to give birth, a maternity team developed an app to help them decide.
There is plenty of choice when regarding places to give birth if you are a woman living in the Portsmouth area. There are three freestanding midwifery-led units, an integrated unit and a consultant-led labour ward.
Despite this choice, not many women were making a conscious choice to give birth in the units or at home. This was in spite of a flexible midwifery workforce to support one-to-one care in labour.
Data from the maternity management system PROTOS demonstrated that many women were undecided about their choice of birthplace at the time of booking and that a high number of low-risk women were birthing in the obstetric unit. The majority of women registered no preference for place of birth by 36 weeks’ gestation. The service wanted to increase the number of women having a clear preference for place of birth, ideally by 36 weeks.
So we welcomed the Birthplace in England research programme (Hollowell et al, 2011), as we hoped that it would provide the evidence needed by midwives and mothers to make a more considered decision about place of birth.
The challenge was to translate this information into an easily accessible format that women and midwives could use when discussing place of birth, rather than relying on a leaflet.
Of course, midwives provide women with information about the risks and benefits of place of birth in conversation, a method that is variable and potentially subjective. As well as gleaning details from their midwife, women access information about safety and place of birth from the internet, media and friends and family. This appears to shape their thoughts and feelings about where to give birth.
The team at Portsmouth wanted to offer women choice, unbiased evidence-based information and engage them in a shared decision-making process. A successful application was made to the Health Foundation Shine 2012 scheme; £73,000 was awarded to develop a web app. A multidisciplinary project team, which included a mother, piloted a prototype that was reviewed by women and revised many times.
The app was tested by a pilot group of 236 women who were selected from midwives’ caseloads. Eligibility criteria were that women had to be low risk at booking, have a good understanding of English and due to have their babies in October and November 2013. A control group was retrospectively analysed to explore whether access to the app influenced actual place of birth.
Midwives were trained in the use of the app, as well as the theory of shared decision-making. The innovation was underpinned by a shared decision-making model (Elwyn et al, 2012) and Birthplace outcomes (Hollowell et al, 2011).
Midwives introduced the app after 25 weeks. Women were given a leaflet containing an outline of the project and how to access the app. Records were made of a woman’s decision at booking, at introduction to the app and at other antenatal visits. Final preference was recorded at 36 weeks, following discussion with the midwife. Portsmouth midwives used digital pens and this data was captured using a digital sheet specifically designed to support this project.
At the end of the prototype app, women were asked to complete a user survey, which was embedded in the app. Feedback from the survey, along with interviews and focus groups with women and midwives, was used to shape the final app and a graphics expert was commissioned to design the final product.
We compared the data recorded at booking with the information recorded at 36 weeks to show that women had reached a preference after having had access to the app.
Of the pilot cohort, nearly a third (73 women) had either delivered before or after the pilot dates or their notes contained incomplete birthplace preference data at 12 or 36 weeks. As a result, they were not included in the final results.
The remaining 163 women had expressed a birthplace preference at both 12 and 36 weeks. Nearly half (45%) had decided a preferred place of birth at their 12-week appointment. This increased to 143 women (88%) at 36 weeks of pregnancy while 23 participants had moved out of the area.
The app’s survey tool, which was embedded in the app and post-pilot surveys, demonstrated that women and midwives liked using the app and it was a helpful tool in communicating and understanding the evidence-based information.
Comments included: ‘Statistics were great, especially when making such an important decision, like where to have your baby’ and ‘it cemented my decision. I knew what I wanted to do, but it gave me more information so that I knew it was the right decision’.
The app was rolled out across the service for all women in June and is attracting interest from other trusts. The team has been highly commended by NHS England for its work in patient participation. They are delighted that others share their enthusiasm for the app and consider the project to have been a great success.
Implications for practice
- This project was the first of its kind to integrate research findings into a tool for women and midwives to use together to discuss birthplace choices
- Providing women with standardised nonsubjective information about place of birth appears to influence their preference and acceptable to them
- Incorporating shared decision-making into practice ensures women are active partners in decision-making
- Understanding the preferences of local women can assist in planning maternity services, so that midwives are in the right place for the right women.
Gill Walton, director of midwifery,
Greta Westwood, head of nursing, midwifery and AHP research,
Emily Gaskell, My Birthplace® project manager,
Mandy Forrester, My Birthplace® project midwife,
Mandy Grosvenor, My Birthplace® project midwife,
Portsmouth Hospitals NHS Trust